Provider Demographics
NPI:1568455889
Name:PERFORMANCE REHAB, INC
Entity Type:Organization
Organization Name:PERFORMANCE REHAB, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:S
Authorized Official - Last Name:WALTERS
Authorized Official - Suffix:
Authorized Official - Credentials:OTR L
Authorized Official - Phone:601-308-5117
Mailing Address - Street 1:PO BOX 720610
Mailing Address - Street 2:
Mailing Address - City:BYRAM
Mailing Address - State:MS
Mailing Address - Zip Code:39272-0610
Mailing Address - Country:US
Mailing Address - Phone:601-308-5117
Mailing Address - Fax:601-308-5103
Practice Address - Street 1:950 EAST COUNTYLINE ROAD
Practice Address - Street 2:SUITE A
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157
Practice Address - Country:US
Practice Address - Phone:601-308-5117
Practice Address - Fax:601-308-5103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-23
Last Update Date:2017-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS0524742261QP2000X, 261QX0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09326565Medicaid
MS0007769666OtherAETNA PIN #
MS0007769666OtherAETNA PIN #